HomeMy WebLinkAboutApplication 765 Sullivan Ave (6) TOWN OF SOUTH WINDSOR HEALTH DEPARTMENT
s' 1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074—Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
TEMPORARY/SPECIAL EVENT FOOD SERVICE LICENSE APPLICATION
***Must be submitted 2 weeps prior to event"*
EVENT INFORMATION Q n
Event Name: J�� Co�� w\" '\
Event Date(s): t��� r C8 )-Event Time: 3�� �. oz-:i
Event Location: S- Ll!\�\a-S(T�Z i T' ocou—) LI
PERSON IN CHARGE INFORMATION
Last Name: —� First: J1 Cam"1�( � M.I.:
�Street Address: r t-`a 1^I_\.k r �V- Apartment/Unit#:
City: a v r' State: �j Zip: �IYUyL�
Phone: \'� E-mail
b / CX Uu'0 Address:
ORGANIZATION REPRESENTED (IF ANY)
Representing: � f SMcy-e `<
Street Address: C o,� /�'�IJ,_U�i 1 Apartment/Unit#:
J t'i -
City: State: Zip:
Phone: E-mail Address:
QUALIFIED FOOD OPERATOR (INCLUDE COPY OF CERTIFICATE) YES NO
Name:
Certificate#: 1 L\ U-)C,;1 (CJ_`--' Date:
ADDITIONAL INFORMATION J J
Water Supply: YES �4 N0 r_1 Wastewater Disposal YES NO [_
Base of
Electrical: YES _ -NO ( Operations: �Ga\l�Vk�C- ` ��y�� ��UY�h l+ ���+n�CT-
MENU`\ "(PLEASE LIST ALL MENU ITEMS IN AS MUCH DETAIL AS POSSIBLE)**
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�C.i.L �►(�` (�c ,\� ��l lit.., � O_(U- �l ;"SZ-t1 �C'i t�� �u 1 � J
****PLEASE DRAW A DETAIL DIAGRAM OF FOOD BOOTH ON THE BACK OF THIS FORM.
USING THE GRAPH PICTURE ON THE BACK OF THIS APPLICATION****
The food preparation and storage areas must be covered if event is outdoors. Be sure that the
tents used for overhead cover are fire-rated. oer the South Windsor Fire Marshal's office.
AGREEMENT AND SIGNATURE
By submitting this application,I affirm that the facts set forth in it are true and complete.I understand that any false statements or other
misrepresentations made on this application may result in immediate shutdown or re Y porary Food Service License for the Town
of South Windsor. Temporary Food Service License will be issued after the Food In=1 his/her inspection.
(PleasenPrint) e SEP 19 7013
Applicant Signature: f SOUTH WINflSOFinate:
�l HEALTH DEPT. 113' S
k
70
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�F c.5}ov r
Ser%j',ck r`
OFFICE USE ONLY
Inspector Name:
(Please Print):
Inspector Date:
Signature:
Food Class: 1❑ 2❑ 3❑4❑ FEE: $50, Nonprofits exempt
Temporary Food Uoense#: Expiration Date:
Payment: Date Received:
I 6* (M� a\15 a
5. How will the food be protected?
Food must be protected during storage, preparation,display,service and transportation. Cooking to order will
lessen the chance for bacterial growth,which may occur prior to service.
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6. How will tTie all utensils and food contact surf be washed,rinsed and sanitized?
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7. Where will excess food(Potentially hazardous and non-potentially hazardous foods),dry goods,and single service
items be stored?
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S. Where will ware wash dete gents dna�sanrt rsCbe stored?
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9. How will condiments and single service items(cups,plates,utensils,etc.)be dispensed?
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10. What method of garbage disposal will be used?